Endoscopy 2022; 54(09): 839-847
DOI: 10.1055/a-1753-9801
Original article

Risk factors and long-term course of gastroesophageal reflux disease after peroral endoscopic myotomy: A large-scale multicenter cohort study in Japan

 1   Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
,
 2   Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
 3   Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
,
 4   Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
,
Hirofumi Abe
 5   Department of Gastroenterology, Kobe University Hospital, Hyogo, Japan
,
Junya Shiota
 6   Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
,
Chiaki Sato
 7   Division of Advanced Surgical Science and Technology, Tohoku University School of Medicine, Miyagi, Japan
,
Masaki Ominami
 8   Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
,
 9   Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
,
10   Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
,
Hisashi Fukuda
11   Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan
,
Ryo Ogawa
12   Department of Gastroenterology, Faculty of Medicine, Oita University, Oita, Japan
,
Jun Nakamura
13   Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
,
Tetsuya Tatsuta
14   Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Aomori, Japan
,
Yuichiro Ikebuchi
15   Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine Tottori University Faculty of Medicine, Tottori, Japan
,
Hiroshi Yokomichi
16   Department of Health Sciences, University of Yamanashi, Yamanashi, Japan
,
Suguru Hasegawa
 1   Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
,
Haruhiro Inoue
 4   Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
› Author Affiliations
Supported by: JGA Clinical Research Grants, Multicenter Research Grant of The Japanese Foundation for Research and Promotion of Endoscopy 2021–1

Abstract

Background Gastroesophageal reflux disease (GERD) and reflux esophagitis remain problems after peroral endoscopic myotomy (POEM). This study aimed to elucidate the risk factors and long-term course of reflux esophagitis and symptomatic GERD after POEM.

Methods This multicenter cohort study involved 14 high volume centers. Overall, 2905 patients with achalasia-related esophageal motility disorders treated with POEM were analyzed for reflux esophagitis, severe reflux esophagitis (Los Angeles classification C or D), and symptomatic GERD.

Results Reflux esophagitis was diagnosed in 1886 patients (64.9 %). Age ≥ 65 years (risk ratio [RR] 0.85), male sex (RR 1.11), posterior myotomy (RR 1.12), esophageal myotomy > 10 cm (RR 1.12), and gastric myotomy > 2 cm (RR 1.17) were independently associated with reflux esophagitis. Severe reflux esophagitis was diagnosed in 219 patients (7.5 %). Age ≥ 65 years (RR 1.72), previous treatments (RR 2.21), Eckardt score ≥ 7 (RR 0.68), sigmoid-type achalasia (RR 1.40), and esophageal myotomy > 10 cm (RR 1.59) were factors associated with severe reflux esophagitis. Proton pump inhibitors (PPIs) were more effective for reflux esophagitis at 5-year follow-up (P = 0.03) than after 1 year (P = 0.08). Symptomatic GERD was present in 458 patients (15.9 %). Symptom duration ≥ 10 years (RR 1.28), achalasia diagnosis (RR 0.68), integrated relaxation pressure ≥ 26 (RR 0.60), and posterior myotomy (RR 0.80) were associated with symptomatic GERD. The incidence of symptomatic GERD was lower at 5-year follow-up compared with that after 1 year (P = 0.04), particularly in PPI users (P < 0.001).

Conclusions The incidence of severe reflux esophagitis was low after POEM, but excessive myotomy for older patients with previous treatments should be avoided. Early phase symptomatic GERD is non-acid reflux dependent and the natural course is favorable, basically supporting conservative treatment.

Tables 1 s–5 s, Figs. 1 s–3 s



Publication History

Received: 16 September 2021

Accepted after revision: 03 January 2022

Article published online:
16 February 2022

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